cepn cardiovascular education event · (14%)." the alcohol paradox – people of lower ses...

Barnet Public Health 20th June 2019

CEPN Cardiovascular education event

N C L North Central London Sustainability and

Transforma7on Plan

Stroke admissions with history of atrial fibrilla7on not prescribed an7coagula7on prior to stroke, 2017/18, by CCG (per cent)

2 PHE (2019)


Transforma7on Plan

The detec7on and management opportunity for AF

3

A third of pa6ents undetected

A quarter of those detected and eligible not an6coagulated


Transforma7on Plan

Diabetes diagnosed prevalence (2017/18) compared to es7mated diabetes (2017)

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Source: PHE (2019)


Transforma7on Plan

Percentage of people achieving their treatment targets for type 2 diabetes, 2017/2018

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Type 2 diabetes CCG Comparator CCGs STP England

HbA1c <= 58 mmol/mol (7.5%) 64.4 65.6 64.8 65.8

Blood Pressure <= 140/80 72.0 75.7 74.4 73.8

Cholesterol < 5 mmol/L 76.3 77.6 77.0 76.6

All Three Treatment Targets 38.2 41.6 40.5 40.1


Transforma7on Plan

The hypertension detec7on opportunity

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Transforma7on Plan

The hypertension management opportunity

7


Transforma7on Plan

Local need for ac7on: Health inequali7es

Some groups are more likely to die under the age of 75 from CVD: • Men • People with serious mental illness • People from Black Caribbean and Black African ethnic backgrounds

They are also more likely to have some key risk factors: Smoking prevalence is almost 40% higher in the most deprived areas (21%) compared to the least deprived (15%).

People who never worked or are on long time employment are two times more likely (35%) to be physically inactive than people in managerial positions (14%).

The alcohol paradox – people of lower SES drink less than people of higher SES (24% vs. 28% drink more than 14 units per week), but they experience greater harms (twice as many alcohol-specific admissions).

NCL Preven7on: ShiRing the focus to Tobacco, Alcohol and Obesity Preven7on Julie BilleU, Director of Public Health (Camden and Islington) and Senior Responsibility Officer NCL Preven6on Mubasshir Ajaz, NCL Preven6on Programme Manager – North London Partners Alexander Lawless, Noor Alabdulbaqi, Alice Wynne – Knowledge Intelligence and Performance Team, Camden and Islington Public Health

Why do we need a focus on preven7on and early interven7on?

•  Huge propor6on of the current burden of ill health, disability and early death is avoidable

•  Just under a quarter of all deaths registered in England are from causes considered avoidable (Figure 1) through good quality healthcare or wider public health interven6ons (1)

•  World Health Organiza6on (WHO) es6mates that among risk factors that cause premature deaths in England (2), the top five are:

–  smoking, poor diet, high blood pressure*, obesity, and alcohol and drug use.

–  air pollu6on and lack of exercise are also significant. •  These health behaviours not only cause disease but

exacerbate exis6ng condi6ons, and are associated with poorer outcomes and early death.

•  The health and care system is under huge strain – preven6on and earlier interven6on has to be a key part of future system sustainability, as well as delivering wider societal and economic benefits

1. Avoidable Mortality in England and Wales, ONS; 2 WHO, Global Burden of Disease Study * Seen as both a symptom of risky behaviour and a pre-‐cursor to other morbidi6es 10

Figure 1 – Number of deaths considered avoidable as a propor7on of all deaths registered in 2015 (England and Wales 2015)

Case for Preven7on in North London

Almost half of people in North Central London (NCL) have at least one

modifiable risk factor (e.g. smoking, poor diet) that is pueng their health at risk,

but they have not yet developed a long term

health condi6on. Between 2012 and 2014, around 20% (4,628) of

deaths in NCL were from preventable causes

Within NCL, the number of overweight children aged 10 to 11 years is much higher than the England

average in three of the five boroughs – Enfield,

Haringey and Islington. Being overweight is partly responsible for more than a third of all long term health condi7ons in NCL.

Smoking contributes to around one in six early deaths of local people. Smoking causes over 9,000 stays in hospital amongst NCL residents each year. However, in

2014/15, only 4% (10,979) of 227,567 smokers in NCL received support through stop smoking services. Of

those who did, 52% successfully quit smoking

at four weeks.

Alcohol-‐related hospital stays are much higher

than average in Islington. Deaths directly related to alcohol-‐specific condi6ons remains higher than the

London average in Camden and Islington, and

similar to London in Haringey.

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Case for Preven7on in North London

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Figure 2 -‐ Breakdown of male and female life expectancy gap by cause of death

The biggest killers and the biggest contributors to the differences in life expectancy across NCL are circulatory diseases and cancer, for which health behaviours are key factors (Figure 2).

Focus on Tobacco

Source: Canoe Health

Na7onal Outlook

Source: NHS Digital Sta6s6cs on Smoking -‐ England 2018 and Cancer Research UK 14

•  Smoking rates con6nue to fall na6onally, however, smoking s6ll accounts for more years of life lost than any other modifiable risk factor.

•  It remains the single largest cause of health inequali6es and premature death, responsible for 17% of all deaths in people aged 35+.

•  Around 6.1 million people in England s6ll smoke.

NCL Context

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1 in 6 people across NCL are

smokers cos7ng

society £331m/

year

§  All NCL CCG's are not significantly different to the London and England average prevalence of smoking.

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Hospital Admissions and Cost

•  Smokers see their GP over a third more onen than non-‐smokers, and smoking is linked to nearly half a million hospital admissions each year (Dept. of Health, 2017).

•  The annual cost of smoking to the public is es6mated to be £13.8 billion in England*. •  Of that, direct costs to the NHS are es6mated to be ~£2 billion and costs to social care ~£1 billion •  Smokers that manage to quit, reduce their life6me cost to the NHS and social care providers by 48%.

*PHE (2016), Local Health and Care Planning: menu of preventa6ve interven6ons

£0.00

£200.00

£400.00

£600.00

£800.00

£1,000.00

Hospital admission

GP visit Outpa6ent visit

Prescrip6ons Prac6ce nurse visit

Ann

ual cost in £ millions

Es7mated Smoking-‐Related Burden on NHS

Primary Care

•  Smokers visited their GP 35% more than non-‐smokers in 2015/16

•  The number of primary care prescrip6ons for nico6ne replacement therapy (NRT), varenicline and bupropion has fallen in England, Wales and Scotland at rates which are much steeper than the fall in the smoking prevalence rate.

•  In England, levels of NRT dispensed in primary care in 2016-‐17 were around 25% of what was dispensed in 2005-‐06.

17 Source: NHS Digital and ONS 2009-‐17

Quifng Rates – NCL

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•  The NCL average rate of successful quipers at 4 weeks is lower than that of London and England.

•  No NCL borough has a

quieng rate above the London or England average.

•  Although Enfield data is missing in the latest numbers from PHE, 2014/15 rates indicated 3938.1 quit rate per 100,000 popula6on aged 16+.

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Inequality in Smoking

•  Smoking prevalence is almost 40% higher in the most deprived areas (21%) compared to the least deprived (15%).

•  The propor6on of current smokers was significantly higher among unemployed persons (29.6%) when compared with those who were employed (15.5%) and economically inac6ve (13.4%)

•  Those with a degree had the lowest propor6on of current smokers (7.6%), which is around a quarter of the propor6on among those with no qualifica6ons (29.1%)

•  Smokers were less likely to report having very good health and more likely to report having very bad health, when compared with those who have never smoked

•  People smart smoking at an early age, with 66% before the age of 18 and 83% before the age of 20.

Source: Annual Popula6on Survey -‐ ONS

What works?

Source: PHE Health Mapers 2018

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•  Around 60% of all people who smoke are intending to quit, 11% of which aim to do so within 3 months.

•  Smokers are 4 6mes more likely to quit with support than doing so alone, yet 60% of smokers s6ll try to quit unaided.

•  Licensed medica6on and an unlicensed nico6ne containing product (NCP) consecu6vely had the highest self-‐reported quit rate (74%) in England, while other licensed medica6ons had more than 50% quit rates*.

•  Offering Very Brief Advice (VBA) to all hospitalised smokers, regardless of admieng diagnosis is effec6ve, according to a Cochrane Review**.

*NHS Digital (2018). Sta6s6cs on NHS Stop Smoking Services in England hpps://files.digital.nhs.uk/CC/D8DC38/stat-‐stop-‐smok-‐serv-‐eng-‐q4-‐1718-‐rep.pdf ** hpp://www.ncsct.co.uk/usr/pub/interven6ons-‐for-‐smoking-‐cessa6on-‐in-‐hospitalised-‐pa6ents.pdf

Opportuni7es

•  BeUer coordina7on between Stop Smoking Locally commissioned services (LCSs), GPs and Pharmacists on referrals, prescrip6ons and follow-‐ups

•  Provision of Very Brief Advice (VBA) and Nico7ne Replacement Therapy (NRT) to all hospitalised smokers

•  Provision of Carbon Monoxide (CO) Monitoring to all pregnant women in all NCL Trusts

•  Improved focus on suppor6ng people with Mental Health Illnesses to quit smoking

•  Upscaling exis6ng cessa6on services and preventa6ve interven6ons to reach more smokers and those at risk

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NHS Long Term Plan

Significant new contribu6on towards a smoke-‐free England, using Opawa Model for Smoking Cessa6on By 2023/24, all people admiped to hospital who smoke will be offered NHS-‐funded tobacco treatment services. The model will also be adapted for expectant mothers, and their partners, with a new smoke-‐free pregnancy pathway including focused sessions and treatments. A new universal smoking cessa6on offer will also be available as part of specialist mental health services for long-‐term users of specialist mental health, and in learning disability services

Focus on Alcohol

Na7onal Outlook

*The Public Health Burden of Alcohol and the Effec6veness and Cost-‐Effec6veness of Alcohol Control Policies: An evidence review 2016 **NHS Long-‐Term Plan 2018 ***PHE 2018. hpps://www.gov.uk/government/publica6ons/alcohol-‐and-‐drug-‐preven6on-‐treatment-‐and-‐recovery-‐why-‐invest/alcohol-‐and-‐drug-‐preven6on-‐treatment-‐and-‐recovery-‐why-‐invest

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220,000 children in England live with an alcohol dependent parent

£3.5 billion is the cost of alcohol to the NHS each year in England

167,000 working years were lost to alcohol in 2015

58% adults (16+) drank alcohol in the previous week in 2017

In England there were an es7mated 589,101 dependant drinkers in 2016/17

•  Among those aged 15 to 49 in England, alcohol is the leading risk factor for ill health, early mortality and disability and the finh leading risk factor for ill health across all age groups*.

•  Alcohol contributes to condi6ons including cardiovascular disease, cancer and liver disease, harm from accidents, violence and self-‐harm, and puts substan6al pressure on the NHS**.

•  The financial burden of alcohol is substan6al, with es6mates showing that the social and economic costs of alcohol related harm amount to £21.5bn in England***.

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•  England had the highest propor6on of adults (57.8%) who said they drank alcohol in the previous week in Great Britain, this was higher than Scotland (53.5%) and significantly higher than Wales (50%).

•  While young people aged 16 to 24 years in Great Britain are less likely to drink than any other age group; when they do drink, consump6on on their heaviest drinking day tends to be higher than other ages

•  31% of men and 16% of women drank over 14 units in a usual week, placing them at an increased risk of alcohol-‐related harm

Drinking Habits

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NCL Context

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Hospital Admissions and Mortality Related to Alcohol

•  Hospital admissions in NCL for alcohol-‐related condi6ons is higher than the London average for those aged 40-‐64 and 65+ and higher than the na6onal average for those aged 65+.

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Inequality in Alcohol

People of lower socioeconomic status drink less than people of higher socioeconomic status (24% vs. 28% drink more than 14 units per week), but they experience greater harms (twice as many alcohol-specific admissions).

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Access to specialist treatment services

What works?


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•  Iden6fica6on and Brief Advice (IBA) can reduce weekly drinking by between 13% and 34%, resul6ng in 2.9 to 8.7 fewer drinks per week, reducing rela6ve risk of alcohol-‐related condi6ons by ~14%.

•  Alcohol Care Teams in in acute hospitals with clearly defined pathways linking referrals with the community opera6ng daily with par6cular focus on weekends can reduce admissions and A&E apendances.

•  Working with licencing teams and businesses on pricing, access, availability and adver6sing.

•  Par6cular focus on vulnerable popula6on groups, including children and young people in terms of safeguarding and domes6c violence, older people in terms of social isola6on and mental health and those deemed to be at high risk of heavy drinking (locally iden6fied).

Opportuni7es •  Establish and/or op6mise alcohol care teams

(ACTs) in hospitals •  Provide/Upscale alcohol Iden7fica7on and

Brief Advice (IBA) in primary and secondary care seengs

•  Establish Alcohol Asser7ve Outreach Teams (AAOT) to reduce repeat users of hospital and other services such as police and social services

•  Formulate a clear strategy for NCL with dis7nct care pathways

•  Sustained engagement with high volume users and a family approach to alcohol preven7on which goes beyond safeguarding for children and young people from parents who are high risk users

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NHS Long Term Plan

NHS Long Term Plan states over the next five years: §  Hospitals with the highest rate of alcohol

dependence-‐related admissions will be supported to fully establish ACTs

§  Funding will be from local CCGs’ health inequali6es funding supplement in partnership with LA commissioners

§  Will be delivered in the 25% of worst affected hospitals, preven6ng 50,000 admissions over 5 years

Focus on Obesity

Na7onal Outlook

•  Overweight and obesity are terms that refer to excess body fat which is calculated by body mass index (BMI) and waist circumference (WC).

•  Obesity reduces life expectancy by an average of 3-‐10 years and is responsible for more than 30,000 deaths each year.

•  Obesity increases the risk of developing a whole host of diseases:

–  5 6mes more likely to develop type 2 diabetes –  increased risk of certain cancers, including 3

6mes more likely to develop colon cancer –  more than 2.5 6mes more likely to develop

high blood pressure -‐ a risk factor for heart disease

Source: PHE Health Mapers: obesity and the food environment (2017)

NCL Context: Prevalence

Source: QOF, 2012-‐2017

By 2050 60% of men and 50% of women could be clinically

obese. Without ac6on, obesity-‐related

diseases are es6mated to cost society

£49.9 billion per year.

Source: Foresight Report on Reducing obesity: future choices (2007)

NCL Context: Admissions with a primary diagnosis of obesity

Source: NHS Digital 2013-‐2016

1 in 2 people in

NCL are overweight or obese

costing the NHS £417m/year

•  It is es6mated that the NHS spent £6.1 billion on overweight and obesity-‐related ill-‐health in 2014 to 2015, with costs to the wider society es6mated to be £27 billion

Physical ac7vity

Source: PHE, 2016 (Health mapers: geeng every adult ac6ve every day)

•  Mee6ng recommended physical ac6vity guidelines reduces risk of long-‐term condi6ons by 20-‐40%

NCL Context: Physical ac7vity

Source: PHOF, 2016/17

1 in 4 people

in NCL are physically inactive

costing the society £84m/

year

•  Poor diet and physical inac6vity are causal factors of obesity, however it is a complex issue with many drivers beyond behaviour, including:

•  Environment •  Gene6cs •  Culture

•  Mee6ng recommended physical ac6vity guidelines reduces risk of long-‐term condi6ons by 20-‐40%

Obesogenic Environment

•  PHE es6mated in 2014 that there were over 50,000 fast food and takeaway outlets, fast food delivery services, and fish and chip shops in England.

•  More than a quarter of adults and one finh of children eat food from out-‐of-‐home food outlets at least once a week.

•  These meals tend to be associated with higher energy intake; higher levels of fat, saturated fats, sugar, and salt, and lower levels of micronutrients.

•  All NCL boroughs except Barnet* have planning policies that either restrict hot food takeaways (A5 use) near schools (eg 400m) or by level of concentra6on on streets (eg not more than 5% of all proper6es or more than two next to each other)** 37


*Barnet is conduc6ng a healthy weights needs assessment that will inform future planning around hot food takeaways **Greater London Authority: London Plan topic paper: Hot food takeaways (2018)

Childhood Obesity

•  Over one finh of 4 to 5 year old children, more than a third of 10 to 11 year olds are either obese or overweight.

•  Nearly a third of children aged 2 to 15 are overweight or obese and on average consume up to 500 extra calories per day; younger genera6ons are becoming obese at earlier ages and staying obese for longer.


Year Barnet Recep6on

Year 6

2006/7 20.7 32 2017/18 19.9 33.5

Camden Recep6on

Year 6

21.2 33.9

20 36.5

Islington Recep6on

Year 6

22.9 38

22.3 38.1

Haringey Recep6on

Year 6

25.4 38.3

22 37.2

Enfield Recep6on

Year 6

25.1 36.4

24.9 40.8

England Recep6on

Year 6

22.9 31.6

22.4 34.3

Better than England

Comparable to England

Worse than England

NCMP: Childhood combined overweight and obesity prevalence across NCL*

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Inequality in Obesity

Source: NCMP NHS Digital 2017/18

People who never worked or are on long time employment are two times more likely (35%) to be physically inactive than people in managerial positions (14%).

What works?


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•  Diabetes Preven6on Programme evidence shows that people that engage with the length of the programme achieve between 3.3 to 3.7kg weight loss

•  Evidence-‐based weight management services (including all 6ers) are cost-‐effec6ve and outcomes include moderate to significant weight loss

•  Linkage of weight management programmes with NHS health checks, NCMP and the DPP are beneficial to all programmes

•  Comprehensive strategies that include health promo6on and tackling the obesogenic environment through popula6on level interven6ons, place-‐based ini6a6ves and targeted programmes around known risk factors.

Opportuni7es

•  Ensure evidence-‐based weight management services are commissioned across a shared local pathway (between CCG and LA) and upscale exis7ng weight management support programmes which are delivering measurable (and improving) outcomes

•  Use planning standards to control the obesogenic environment to facilitate uptake of nutri6on policy tools and implement Government Buying Standards for food and catering services

•  Integrate weight management and mental health services

•  Support for families on weight management •  Making use of the 1 million contacts NHS has with

pa6ents a day to recognise obesity as an issue in their care pathway and to ini6ate an ac6on plan

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NHS Long Term Plan

§  NHS will provide a targeted support offer and access to weight management services in primary care for people with diagnosis of type 2 diabetes or hypertension with a BMI of 30+

§  Commitment to fund a doubling of the NHS Diabetes Preven6on Programme over next 5 years, including new digital op6on to widen pa6ent choice and target inequality

§  Test an NHS programme suppor6ng very low calorie diets for obese people with type 2 diabetes

§  Con6nue to take ac6on on healthy NHS premises (Hospital food standards)

§  Nutri6on and understanding healthy weight training for clinicians (medical school)

NHS Long-‐term Plan and Inequali7es

•  To help tackle health inequali6es, NHS England will base its five year funding alloca6ons to local areas on more accurate assessment of health inequali6es and unmet need.

•  As a condi6on of receiving Long Term Plan funding, all major na6onal programmes and every local area across England will be required to set out specific measurable goals and mechanisms by which they will contribute to narrowing health inequali6es over the next five and ten years.

•  The Plan also sets out specific ac6on, for example: –  to cut smoking in pregnancy, and by people with long term mental health problems –  ensure people with learning disability and/or au6sm get beper support –  provide outreach services to people experiencing homelessness; –  help people with severe mental illness find and keep a job –  improve uptake of screening and early cancer diagnosis for people who currently miss out

•  Each of our proposed ini6a6ves includes a specific focus on reducing the inequali6es for vulnerable groups

Integrated care systems with a focus on popula7on health

•  ICSs as the “organising model” for health and care •  Place-‐based partnerships focused on use of system resources,

design of services and ul6mately improving health outcomes for a whole popula6on

•  Opportunity to shin focus to preventa6ve, proac6ve care and more upstream factors

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cepn cardiovascular education event · (14%)." the alcohol paradox – people of lower ses...

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